Amount of charge $____________________ 

Name as it appears on the card____________________

Card number__________________________

Expiration date _____/_____(mm/yy)

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Last name, First name

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Department

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Delivery Address (mail box or in-box)

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Contact Person / Telephone # or e-mail

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Office Phone / Message Phone or e-mail

Library Status (Please circle one):      Faculty      Staff      Graduate      PhD Candidate

Please check one regarding Interlibrary Borrowing referral:
___ Refer request to Interlibrary Borrowing automatically if material requested is not at UCB.
___ I will decide on Interlibrary Borrowing referral on a case-by-case basis.

Please check one regarding article delivery:
___ I would like my articles delivered on the Web.
___ I would like my articles delivered in hard copy to my mailbox.

Please read, fill in amount($), and sign in order to establish your account:

My initial deposit is in the amount of $ ___________. I understand that these funds are not refundable, and that if my BAKER account is inactive for a full academic year (July 1 - June 30), my account is subject to closure and the balance forfeited. I hereby authorize the BAKER service to act as my proxy borrower in the Library at UC Berkeley. I agree to use BAKER only for my own research needs, and in compliance with the Library rules and policies. When requesting photocopies, I accept full responsibility for compliance with the copyright law of the United States (Title 17 U.S. Code).

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Signature

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Date